Thursday, April 11, 2013

What if??

Occasionally I will read about a woman who is planning on having a cesarean for the birth of her child, such as Ms. Magee. She's done her research. She knows the risks and benefits of cesarean and vaginal delivery, and is prepared to put up with the static of choosing cesarean. It is her body and her choice.

However, because of my experience with my daughter's birth, and hearing of other women who planned on having a cesarean but ultimately did not - I find myself asking the question "What if?". It is all well and good to know what you want and to pursue it and women should expect to have their choices regarding childbirth respected to the degree possible. But what if the cesarean does not happen, then what?

That is the situation I found myself in after my daughter's birth.

That is the situation I worried about throughout my pregnancy with my son.

When I was pregnant with my daughter - I thought the risk of not delivering by cesarean was fairly small - I knew about 10 percent of women did not make it to their scheduled surgery date, but I also knew that few first time mothers had exceedingly short labours, and that the hospital I was delivering at was a tertiary care facility. I believed that if the hospital could provide emergent cesareans for those who needed them within a half hour, that surely if I did go into labour that I would be able to get a cesarean within two hours, and that it would be extremely unlikely that as a first time mother my labour would be less than two hours. In short, I thought the risk of enduring a labour and vaginal delivery, in the circumstance I was in, was vanishingly small - small enough that I discounted the possibility nearly entirely.

What I did not account for, and should not have needed to account for - was the possibility that the hospital and/or my doctors would fail to actually and reasonably facilitate and respect the choice that had been made. I believed that I might get bumped for more urgent cases, but when the chips were down, if I should happen to actually go into labour - I believed I would be an urgent case and would have my care facilitated (possibly bumping others). I believed that my ability to determine what happened with my own body would be respected to the degree possible. I fully trusted, that the system, while not perfect - would be "good enough" - and completely disillusioned when it proved otherwise.

So now I know what if, what if a chosen cesarean does not happen and a woman endures a vaginal delivery she does not want. I know that when it happened to me - I felt violated; I felt isolated; I felt betrayed; I feared the worse; I felt disempowered; I felt traumatized; I questioned my desire for a subsequent child; and, when I was pregnant with my second child I was anxious; I still worry about the longer run impacts to my pelvic floor and psychological health; I am both angry and numb; and I struggle with the experience and the large chasm between what should have been and what is. I know the answer to the question "what if?" - and know that the answer to that question is often not, "The woman will have a vaginal delivery like the billions of women before her, will likely have a healthy child, and get over it so it really is not a big deal to force her to have a vaginal delivery she does not want."

Forcing women who do not want to have vaginal deliveries, when cesarean is an acceptable and available alternative, to have vaginal deliveries - is a big deal, it is wrong, it needs to be addressed and stopped. Further, women need to be confident that their care providers and the facilities they go to give birth will actually and reasonably facilitate and respect the choices that they have made.


  1. Thank you again for your blog and for championing this topic. I am in the final weeks of my first pregnancy and have had an MRC date scheduled for some time. I spoke with my OB about MRC before I even got pregnant, and would not have gotten pregnant had that option not been available. But now I'm anticipating an earlier (hopefully not pre-term) birth and have no confidence I will be allowed a c-section prior to my scheduled date in week 39. My OB's first answer, when I asked recently, was that perhaps in labor I would change my mind (!!!). It's terrible to find myself daydreaming about a breech baby or other complication that would "justify" a c-section. I think what will be most difficult, if I do go into labor early, is attempting to strongly advocate for my MRC and at the same time attempting to get mentally and emotionally "okay" with the labor and vaginal delivery happening right then. I wish I could be confident that my choice would be respected regardless of when I went into labor, or which doctor was on call, so that I could focus on other things that should be more important.

  2. I live in Victoria and just stumbled upon your blog from Dr. Amy's site, and you've confirmed all my fears about my plans for maternal request c-sections. I am a ways off from childbirth (only 29, hoping to delay another four years at least), but my siblings and spouse's siblings have started having kids, and I'm already starting to worry about my own pregnancy options. How did you manage to secure your son's c-section?

    1. Hi Anonymous - a lot can change in the space of four years - and perhaps things have changed since I had my daughter (I am aware that Victoria General now has dedicated obstetric anaesthesiology, and they may have changed how they book maternal request cesareans - if/when you are pregnant they won't give you a date/time on the elective slate, I would think that travelling to access care might bring a lot of peace of mind). Locally, I am aware that a low-risk woman will have a difficult time getting referred to an obstetrician for her prenatal care - she will be referred either to a midwife or to a GP who does obstetrics as part of their practice. If she is firm, she might be able to get an OB to "co-manage" her prenatal care with either a GP or a midwife. It might also be possible to go with an OB in Vancouver who co-manages with a local provider - this was offered to me for my son, but I was not comfortable with having more than one care provider during my pregnancy so I elected to travel between Vancouver and Victoria for my prenatal care. I have recently been made aware of an OB in Victoria who may be supportive and know of one in Campbell River and the OB I used in Vancouver for the delivery of my son (excellent OBGYN and I was really happy with St. Paul's) - also I insisted on being referred to an OB and not a GP or midwife. You are probably best to have names to ask to be referred to rather than chancing it.

      Regardless, when the time comes, keep an open mind - research your options (Choosing Cesarean, by Pauline Hull and Magnus Murphy is an excellent book), have a conversation with your care provider about what is the best choice in your particular circumstance, and make a choice that best meets your needs under the circumstances. Good luck! (And feel free to email me - qualitycareforbcmothers (at) gmail (dot) com .

  3. I think that one of the major deficiency in the system in Victoria is exactly as you suggest - lack of informed choice. I do find it interesting that a woman cannot request to be seen by an OB without a medical indication. I am not sure what the solution is, but we seem to have a system that will go out on a limb for support choice for the natural birth crowd, but condemn those who request intervention. I think that the pendulum has swung too far and needs to come back to the middle ground.

    1. Is Tokophobia considered a medical indication for an OB consult? Many women who are tokophobic are unaware that they are and present as asking for a maternal request cesarean. There is some research (out of Norway I believe - and I do not that it suffers from an extremely small sample size) that suggest those who have vaginal deliveries against their wishes are at a very high risk of developing PTSD.

    2. I would absolute believe that. I think that tokophobia is a VERY GOOD reason for an obstetrical consult. I think that a late referral (say after 32 weeks) is not beneficial to the women or fair to the OB/GYN receiving the consult. It is still a major abdominal surgery that the patient is asking for, and there is no way I would feel comfortable after a single visit to have really explored the women's concerns and needs regarding delivery. Some of the women I have met have more issue with control than the actual mode of delivery. In some cases I have work with these moms to facilitate a vaginal delivery on their terms, with the back-up plan of a C-section. This takes time to develop a two-way, trusting and respectful relationship. I have had one patient that I wish I had met pre-conceptually, because she had such deep rooted fears about labour and delivery, that she has a negative pregnancy experience, because she spent the entire time fearing delivery. In the end, she attempted a vaginal birth, but with the very first variation in heart rate I did a C-section. She not surprisingly is more happy with her delivery than with her pregnancy.

      I think that a simple patient request should be enough to trigger an OB consult. I think I would like to set up a self referral preconception clinic for counselling about anything. I am just not sure how my funding would work for that, but I am looking into it.